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National Guard Black Belt Training National Guard Black Belt Training UNCLASSIFIED / FOUO UNCLASSIFIED / FOUO Module 46 Mistake Proofing (Poka Yoke)

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Page 1: NG BB 46 Mistake Proofing

National GuardBlack Belt Training

National GuardBlack Belt Training

UNCLASSIFIED / FOUO

UNCLASSIFIED / FOUO

Module 46

Mistake Proofing (Poka Yoke)

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CPI Roadmap – Improve

Note: Activities and tools vary by project. Lists provided here are not necessarily all-inclusive.

TOOLS

•Brainstorming

•Replenishment Pull/Kanban

•Stocking Strategy

•Process Flow Improvement

•Process Balancing

•Standard Work

•Quick Change Over

•Design of Experiments (DOE)

•Solution Selection Matrix

• ‘To-Be’ Process Mapping

•Poka-Yoke

•6S Visual Mgt

•RIE

ACTIVITIES• Develop Potential Solutions

• Develop Evaluation Criteria

• Select Best Solutions

• Develop Future State Process Map(s)

• Develop Pilot Plan

• Pilot Solution

• Develop Full Scale Action/

Implementation Plan

• Complete Improve Gate

1.Validate the

Problem

4. Determine Root

Cause

3. Set Improvement

Targets

5. Develop Counter-

Measures

6. See Counter-MeasuresThrough

2. IdentifyPerformance

Gaps

7. Confirm Results

& Process

8. StandardizeSuccessfulProcesses

Define Measure Analyze ControlImprove

8-STEP PROCESS

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Learning Objective

Use Lean techniques to improve the process

Understand and apply Mistake Proofing tools and techniques

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Class Exercise - Inspection

Six Sigma Black Belts are assigned to Six Sigma projects. These projects are solved by identifying, measuring, analyzing, improving, and finally controlling the measure of interest. Six Sigma Champions help stomp out barriers to ensure success. Ad hoc teams lend their process and product skills. As the defect levels fall, so does the associated cost of poor quality. Six Sigma projects deliver measurable business results. The Black Belt resource ensures the program’s success.

Purpose: To illustrate that inspection is not only Non-Value

Added but also an ineffective means to achieve quality.

Exercise: You have 60 seconds to count the letter “S” in the

paragraph below. Document your answer below.

Answer: _________

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Mistake Proofing

A poka-yoke device is any mechanism that either prevents a mistake from being made or makes the mistake obvious at a glance

Simple example – applying brake to shift transmission from “park”

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Old Process Assumptions

“Defects are inevitable, but can be caught before

leaving the organization or area (check points,

multitude of inspectors, sampling tables, SPC)”

“A disciplined, well-trained and highly motivated

employee will not make mistakes”

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Quality Goal - 99.9%

Is this Good Enough?

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Quality Goal - 99.9%

If the product were your heart, you would spend almost 9 hours a year in cardiac arrest

There would be 2 unsafe landings at Chicago a day

One hour of unsafe drinking water every 8 weeks

200,000 wrong prescriptions each year

15,000 newborn babies dropped each year

Nine missspelled words on evry page of every magazzine

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New Assumption

It is impossible to eliminate all errors

from any task performed by humans.

Indeed, inadvertent errors are both

possible and inevitable

Errors will not turn into defects if

feedback and action takes place at the

Error Stage

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Poka Yoke: What Is It?

Poka (inadvertent errors) Yokeru (avoid)

Methods for preventing mistakes becoming defects

“Quality at Source”

Can you think of an example of Poka Yoke?

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Mistake-Proofing: Conserve Electricity

Door key-card must be inserted in holder to activate electricity in room

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Forget to shake the Ketchup?

Mistake-Proofing the Ketchup lid?

H.J. Heinz did their best to keep the watery

liquid part of ketchup from soaking your bun.

Their redesigned bottle lid had a little

reservoir around the spout to catch the liquid.

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Self-check to determine if the bag is going to fit

Carry-on Luggage Mistake-Proofing

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Mistake-Proofing the ATM?

New generation ATMs perform transactions without the card leaving your hand.

Chances of leaving your card in the machine remote or impossible

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Uses of Mistake-Proofing

Enforce procedures or sequences

Signal or stop a process if a defect is created

Eliminate choices leading to incorrect actions

Prevent product or process damage

Prevent equipment damage

Prevent personal injury

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Describe the defect (or abnormality)

Identify the location at which defect occurs

Detail current standard procedures

Identify mistakes or deviations from standards

Identify conditions that provoke mistakes

Identify root cause of defect condition

Mistake proofing is significantly easier if true root cause is known

Identify type of Mistake-Proofing device required

Create the device, test and standardize

Steps in Mistake-Proofing

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Why Use Mistake-Proofing?

Why use mistake-proofing?

It works where other techniques don’t

There is lots of evidence of its effectiveness

The Poka Yoke devices tend to be inexpensive and very effective

Why is it important to CPI?

Defects are caused by errors in processes

Defects are waste and cause wasteful activities to deal with them

In a CPI operation, a defect disrupts the balance of work and the flow.

Immediate corrective action is taken to resolve the situation but, it is better to avoid this type of downtime by finding and eliminating the root cause.

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Have you ever done the following?

Driven to work and not remembered it?

Driven from work to home when you meant to stop at a store?

To Err Is Human

It happens to workers too.

Workers finish the day and don’t remember what they have done

After building “green widgets” all morning, the workers put “green parts” on the “red widgets” in the afternoon

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1. Forgetfulness

2. Misunderstanding

3. Misidentification

4. Lack of experience

5. Ignoring rules

6. Inadvertent errors

7. Slowness

8. Lack of standards

9. Surprises

10. Intentional errors

10 Types of Human Error

1. Omitted process step

2. Processing errors

3. Errors in set up of parts

4. Missing parts

5. Wrong parts

6. Processed wrong part

7. Mis-operation

8. Adjustment error

9. Errors in set up of equipment

10. Design or preparation errors in tools, jigs and fixtures

Sources of Defects10 Sources of Defects

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Judgment Inspection Involves sorting the defects out of the acceptable product,

sometimes referred to as “inspecting in quality.”

The consensus in modern quality control is that “inspecting in quality” is not an effective quality management approach.

Judgment inspection does not improve process and should be used only in the short term.

Inspection Techniques

Description

Judgment inspectionAssesses quality of production outputs or sorts out defects from good product. (e.g. inspectors)

Informative inspectionAssesses process by inspecting outputs and using information gained to control the process (a feedback loop) (e.g. SPC).

Source inspectionAssesses beforehand whether the conditions necessary for high quality production to exist (e.g. Poka Yoke).

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Exists at Source of Defect (Root Cause): Checks for factors that cause errors, not the resulting defect

100% Inspection: Uses inexpensive mistake proofing (poka-yoke) devices to inspect

automatically for errors or defective operating conditions

Immediate Action: Operations are stopped instantly when a mistake is made and not

resumed until it is rectified

Source Inspection

Never pass on a defect!

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“The old way of dealing with human error was to scold people, retrain them, and tell them to be more careful … My view is that you can’t do much to change human nature, and people are going to make mistakes. If you can’t tolerate them ... you should remove the opportunities for error.”

“Training and motivation work best when the physical part of the system is well-designed. If you train people to use poorly designed systems, they’ll be OK for awhile. Eventually, they’ll go back to what they’re used to or what’s easy, instead of what’s safe.”

“You’re not going to become world class through just training, you have to improve the system so that the easy way to do a job is also the safe, right way. The potential for human error can be dramatically reduced.”

Chappell, L. 1996. The Pokayoke Solution. Automotive News Insights, (August 5): 24i.

LaBar, G. 1996. Can Ergonomics Cure ‘Human Error’? Occupational Hazards 58(4): 48-51.

Blame the Process Not the Person

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The real question you need to ask: How are you going to detect an error?

automatic, not dependent on human attention

fail in “detect” mode

simple & low cost if possible

Setting Functions

Setting function Description

Physical

(Shingo’s contact),

Checks to insure the physical attributes of the product or process are correct and error-free (e.g. round hole).

Sequencing

(Shingo’s motion step),

Checks the precedence relationship of the process to insure steps are conducted in the correct order (e.g. check list).

Grouping or Counting

(Shingo’s fixed value methods),

Facilitate checking that matched sets of resources are available when needed or that the correct number of repetitions has occurred (e.g. egg tray).

Information enhancement

(Chase and Stewart)

Determines and ensures that information required in the process is available at the correct time and place, and that it stands out against a noisy background.

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Regulatory Function

How are you going to stop the process?

the worker needs to get the message?

By audible or visual warning

By prohibiting further processing

How are you going to eliminate the possibility of error?

The Contrapositive of Murphy’s Law

Simplicity

Symmetry

The real questions you need to ask:

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Regulatory Function

Regulatory Function

Description

Warnings Signals mistake but allows process to continue.

Gagging System shuts down.

Some resetting action required to correct the mistake.

Non-response Action leads to no response.

The process does not crash nor does it proceed.

Self-correct Process stops.

System proposes correction to mistake.

Let’s talk about it Process seeks information about what was really intended.

Teach meProcess associates correct outcomes with incorrect actions.

Co

ntr

ol M

eth

od

s

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“Hard” mistake-proofing: Designing processes and tasks to ensure error-free execution

Anticipating errors to make processes “fail-safe”

Allows for preventive actions to be part of process design

Initiating individual accountability to ensure quality work before handing off to another step in the process

“Soft” mistake-proofing: Creating alarm signals to catch defects as they occur and warn people

Andon: processes and tools to STOP the process when a problem or defect is encountered

Poka Yoke: Preventing Errors

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Level 0 (No Control): Acceptance, Inspection

Level 1 (Mitigation): Minimize Damage

Build into Inspection: for example

Double signals (sound and visual)

Cross footing in financial forms

Level 2 (Detection): Feedback and Control

Build into Process

Checks etc.

Posting Sequence

Feedback should

be immediate!

Level 3 (Avoidance):

– Build into Design

Wrong part or orientation, No fit

Forms design

Level 4 (Replacement):

– Automation or Elimination

Fail Safe

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=> provide clues about what to do:

Natural Mappings

Affordances

Visibility

Feedback

Constraints

Precise outcomes without precise knowledge or action?

Fail Safe (Cont.) Fail Safing means embedding a device or procedure in a process so

that the process will never allow a nonconformity (error) to occur.

The idea of Fail Safing is to prevent inevitable mistakes from turning

into a defect.

Fail Safing requires the ability to discriminate the good from the bad.

Simple Fail Safing methods are the low cost way to parts per million

error rate.

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Which dial turns on the burner?

Stove A

Stove B

Natural Mappings

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How would you operate these doors?

BA C

Push or pull? Left side or right? How do you know?

Affordance

Visibility means making relevant parts visible, and effectively displaying system status

Feedback means providing an immediate and obvious effect for each action taken.

Visibility and feedback

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Is Box Full or Empty?

Before Improvement

• Some boxes were unfilled

• Not found since box was

opaque

After Improvement

• Empty boxes blown off

conveyor

• Pinwheel indicates

airstream functioning

Compressed

Air

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Mistake-Proofing Examples

Redesign the process to eliminate or reduce the possibility of a particular failure mode

A way to avoid mistakes

Make the error impossible

If you cannot prevent the error, modify the process to make the error obvious (detection)

Fixture

Workpiece

Chuck

Correct Position

(can be loaded)

Wrong Position

(cannot be loaded)

Mistake-Proofing Illustrated

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Everyday Mistake-Proofing Examples

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Exercise: GGA Budgeting Recap

The Generic Government Agency (GGA) represents a government agency that is focused on obligating their budgeted dollars

GGA obligates funds by processing Budget Documents (BDs)

GGA’s ability to obtain all necessary products and services is directly related to the efficiency and effectiveness with which it processes Budget Documents

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Exercise: GGA Budget Mistake-Proofing

As a CPI Belt you have been assigned the task of Mistake Proofing the GGA Budget Document.

Brainstorm ideas on how to Mistake-Proof the document for the Generic Government Agency (IT solutions are permitted)

Put the ideas into 2 categories:

Prevention

Control/Warning

Write the ideas on flip charts and be prepared to present back to the group

20 Minutes

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Takeaways

Source Inspection

+

Mistake-Proofing

=

Zero Defects

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What other comments or questions

do you have?